Medical Care Additional Expense Claim Form
CHANCELLOR & CHANCELLOR, INC. SECTION 125 PLAN MEDICAL CARE EXPENSE CLAIM FORM
Date Incurred Name of Service Provider Describe Expense Person for Whom Expense Incurred Net Amount _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ _____________ _____________ _____________ _____________ $____________ Total (enter here and on front of form) $____________ (You may print out this page from your browser or cut & paste into a word processor, fill in your information, and fax/e-mail or mail us the completed form.)